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<br />/ - STATE OP COLORADO s Yr STA7E FILE NUMBER
<br />CERTIFICATE OF DE/"A~H _
<br />1
<br />~ / L
<br />~ L DEGEDENTSNAMEIF I MinOk t II ~ 2. SE% 3. DATE OF OFATN IMOnP Oay Yeap
<br />t"
<br />, Wesley Wade. HERTZOG ale Au ust 26, 2005'
<br />g., a. SO IAL SECUPItt sa AGE-LaN "Sb UNDEP 1 YEAP.: Sc. UNDEq't DAY * S OatE Of SIPiH T. SIPTNPUCE ICny a~tl slala m F°m~9n
<br />4Y. NVMSER &nM1dey (YeeKl (Mahlll.OaY Ypr1 G°Ynlry) "
<br />y~ 521-74-7793' 53_... ° n ~'"a -December 9, "1951 Ha den, CO
<br />&WAS DECEDENT EVER IN, 9a pLpCE OF DFgTN ICh F lyonel"" ~. ,. ""
<br />U9. APMED FOPCE$l
<br />O Yes g1 N° HOSPITAL t +~OTHER ~~
<br />I Zt Inpalle t ^ER/Ou1pa11M1 'n DDq - ' nNU lilp Name O R M vre n00[r l3Ponly1
<br />Sb. FACILRY NpA1E pl I Illf p I lentlnumb ) pc -QTY TOWN OR LOCATION OF OEATN- BO, COUNtt OFDE4iH
<br />I 'Denver Health Medical Center ~ .Denver ~ Denve ,
<br />tO.D LEOENTS USVAL OCCUPATION f00. KINDOF EUSINESS/INDUSTRYY_ lt. ARITAL SiAN9`Mamatl 12.SPoVSE DI eiH, plve malOen nemml
<br />G ekinC I MCpne EUnnpm 1 I rFlnpl le N M rty6, WpReE„
<br />tb nol uae nNreel \ y ~" OlvmceE l$pec/ry{
<br />~ ~ Owner/Operator "' Sand a d Gravel ,~, r'~a. ~Ma2ried"" Beck Millken
<br />13a: RESIDENCE STPTE 13p. COUNtt / iRC WN OR COGA(WN TW 13C. STPEEt qNO HUNGER
<br />/~°` ~1
<br />Colorado . Moffat _p~ ~Crai°"" ~sfR"~.~~'e828 Ashle Road "
<br />I 13e M$IDE 131 21P CODE f9 WgypfiCEDE OFmNI$PANIC ORIGIN d 1RALE?A G I tlM I& DECEDENTS EDUCATN)N lSpecilYpnly M1iOhsi(.
<br />CITY" F~{SpUOyN Y Il p; pICIN COE n 91 KWM1W N 1$p IM y pcempNM6l Elemenlery or aecpnEary
<br />LIfY1T34 [.]~ %~N fll 0.pfc)9Y ~ }k" `~ yy3 ~ IO MrpuOp l!)C°Ilepe 1131M1rpupM1 18 p11 T+1
<br />C b fi°
<br />$"° 81625 ~•sp ry~ -,ti~»`~ -.~ WhiXe SZ 13
<br />1L A HER-NAME Iflry2'MIetlM,L I) \~TY'(y 13 M T 4 l{rtl pO ~mSM~ alVd 1~ PM4Ni NAM ntl nlN wampm eeceasetl'
<br />. "'~'^ Yt ~ ~-~
<br />~, Paul Hertzo ~ `o Ro'semaY ~'$ulae "' ";z eck Hertzo -Wife. - ~ ~ '
<br />20a. METHOD OF DI3P051TION q 2pb PLACE OF 01$P0.41TION}Narm Ic 1 y<nmlry% 2CC, LOCATION-0IIy oI T°wn, Sltle
<br />•e OBUr eI Xl Gremellpn nPempv ll $11 ty "~ r ~ _ ~ q j
<br />OOUnallOn nOll~erlSpecYyl~ ~ ~~ A ~+a ~ '
<br />FFF ~ 1 '` /~ Lakewood Cre ator 1 L ewo - Coi
<br />21; SIGNATURE OF FUNFM DIPECTOP OR PEPSON ACTING A98Ui;N 410~N~NEgNDADDPEB30FfACILITY ;:
<br />I , / 't` * %-Asp~ enl Mortuary 1350 Simms Street
<br />-;,~ wLtal2gwood ~"Color~adgl 2,p: 80401
<br />~~.' 2h PEOI PAR'SSIGNAIURE i ~ „!~ ,w/j' YYU GATE FILEOIMOnM:OaK Yeah .
<br />~` ~' ~._.__:J `~ ~~ ,~, ° a°` SfP Q 2 2005
<br />2.iIME OF DEATH 2O. DATE PR NOUNCED EAD p' P 25 wA9 CORONER NOTIFlEDi
<br />Mon h Dry '` 1'I_F Y i + 3 "`~ / Hpu~ (Yp pl NO) _
<br />C _.
<br />1 - 1746 M Au ust~ ~y 26 ~`~. '"~`206~~ ~` 746 ~ ~ -Yes -
<br />~' TO EECOMpLETEDONLT BY ClP//I~TIFYINO PNYHiCUN pr~'u' "';, y"'~TO EEC pLIT DSY CORONE '
<br />" 26. TOlbe Seel 1 Yk pv enpen tl uneG al lnetl 0 ep4Ge 0 q 2T O INepNe Vl Ymin h IlpDaep~ yDp nl0ntlp111 KCVll9E a11M1p
<br />Ina umN 1 G ne.aa elal a 4,A ,5 ~ e" d ~g~ nmF anew tldece, a 1 aua61/IEnd e e melee. •
<br />SpneWre~ ~Y ~' i .W ~aC ~5/pnaron~.. /l/./1/~/'/~i
<br />~1 28. DAiESIGNED1Mpnlh, DaY. Yaerl 28 GATESIGNED I//ML}'nlM1 Day,Yprl22 / '
<br />30. NAME, TITLE qND MPILING ADDRES$ OF CERTIFIER/CORONEP pypNAlnD ..;r
<br />19 RnhF•rt Rv- Rrnttt County Cmm~rr P 0 Bnx°775777 SrPamhn_ar_ Spsjngc. C~p~ R0477
<br />1 31. NAMf OF ATTENOIN YSICIAN IFOTHERTHAN RTIFIEPIType/P 1 ' '
<br />'4_ 22. MANNER OF DEATH- 33a DQE OFINJURY 33D nME OF ate INJUFM AI 336OESCRISE HOWINJURYOCLURPEO
<br />O Nntunl OPantlln0~ (MOn05 qG Ypp INJURY NVPN9 ~j~~~pfC~
<br />,5_ InaeNgFnon- /Zr:(p'~M q'rp'~NC 'TFk2AWN F~{JNI; L{AJR.l1~ '
<br />Qawltlml ,
<br />1 ou eelermmee ~
<br />OSUk10e Mnner 33s. pUCFONINJSUR~`IAI RpIn; l.rm NraN laelNy pXb 331. LCCATX)NIPo,aN p6 NU~Aarp RUM RMaNUmber GN C°unN.3Yb1
<br />1 oHpminm Hayc~eTi rF~a°~rgrbunds ,, .?" '",ayden -Fairgrounds, "Unincorporated,ROUtt
<br />" y.IMMFDIATE CAV3E lENTERONLYONE CAUSFpER LINE FOR(ak(bAANO([(I Da MIpNl meeedeylry (eµ CWlaep PHphalpry MlpUabne Inlarval between onael'
<br />ppRT enE Oeel
<br />~. F 1 IN Broken Neck ~ k 5
<br />CONDITION$ OUE LOOR A$ACONSEOUENCE OF Inlarval between onael
<br />IF A6T WHICH - - j enO tlealM1
<br />GAVE RISE TO NI l -. 'i ~ '"
<br />IMMEDIATE CAVSE DUE TOOR ASACONSEOUENLE OF Inlarval peMen onael
<br />STATING THE
<br />UNDEPLYING LAUSE ~ entl tleelM1
<br />LAST kl Icl '
<br />I PgRT OTHERbIGNIFICANTCONOITIONS-GVnNIio~NCpnVlbNicglReabU Wln°I relalielUUUNiU -` - 3S. AUTOPSr b.IFYEBwala 11n6hpewmi6Pe '
<br />1/ PART IIa B. elcoM1Ol abuu pEeally,emObrl.' IYp Pr Npl In 6NarminllpaupdeplM
<br />'~... No
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT CQPYOFTH£ OFFICIAL RECORD WHICH IS IN MY CUSTODY.
<br />A.~ Jmgaaay '., ADRS4e 1•a81ReE.1•Btl ... OL-~.'AaXa+~ ". S w~L as
<br />DATE ISSUED -~~ a'
<br />" I u _ 'S~~" n Z 205 '- RONALD S. HV AN _~ -
<br />~ ~ L~4/~J - y" STATE REGISTRAR ;_
<br />6 - "DO not accept unless prepared ov security paper with, engia`ve~ border displaying the Colorado state
<br />seal and signature. of the Registrar PENALTY B~ LAW S°ec[ilin 25 2-I f8, Colorado Revised
<br />Statutes, 1982, if any person alters uses, attempts to use o4 furnishes to another for deceptive use ;. ~ ~
<br />f
<br />`4 = any vital statistics record. NOTE-PALID 1F PHOSQCOPI~D _ , ~
<br />rl v D7/DB YYY 2 ~ -, ~ ~ r
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